Provider Demographics
NPI:1073075222
Name:DERBY, PATRICK (DPM)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:
Last Name:DERBY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15815 SHADDOCK DR STE 130
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-5773
Mailing Address - Country:US
Mailing Address - Phone:813-400-1140
Mailing Address - Fax:813-701-9132
Practice Address - Street 1:2511 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6301
Practice Address - Country:US
Practice Address - Phone:813-879-7850
Practice Address - Fax:813-870-3569
Is Sole Proprietor?:No
Enumeration Date:2019-04-04
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO4422213E00000X, 213EP1101X, 213ES0000X, 213ES0131X, 213ES0103X, 213EP1101X, 213ES0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOPOAVOtherBCBS
FL7333506OtherCIGNA ID
FL114530400Medicaid
FL6605657OtherAETNA
15659126OtherCAQH ID